Abdominal and Pelvic Trauma

Joshua P. Parreco

The vast majority of children presenting to the emergency department with injuries involve a blunt mechanism and approximately 22% of these patients have an intra-abdominal injury.¹
Anatomic considerations that make children more susceptible to abdominal traumatic injury include the following²:
- Compact torso with smaller anterior-posterior diameters with less surface area to dissipate injury force.
- Liver and spleen that extend below the protective costal margin.
- Less fat and abdominal musculature to protect intra-abdominal structures.
Solid organ injury in children typically involves a direct blow to the abdomen such as a bicycle handlebar/sports-related impact or fall from significant height.

INITIAL MANAGEMENT

Start with advanced trauma life support primary (including adjuncts: X-ray, focused assessment with sonography for trauma [FAST], Foley catheter/gastric tube), secondary, and tertiary surveys.
Signs of abdominal injury in children:
- Abdominal distention
- Rebound tenderness
- Involuntary guarding
- Rigidity
- Pelvic instability
- Abdominal abrasions
- Seat belt sign (abdominal bruise) after a motor vehicle collision³
Children who are hemodynamically stable and have signs of abdominal trauma should undergo computed tomography (CT) scan.⁴
Children who have blunt trauma with hemodynamic stability and no signs of abdominal trauma should undergo laboratory testing including the following:
- Hemoglobin and hematocrit
- Urinalysis
- Aspartate transaminase (AST)/Alanine transaminase (ALT)
- Pancreatic enzymes
An abdominal CT scan should be performed for children with⁵
- Gross or microscopic hematuria
- Elevated AST/ALT
Diagnostic peritoneal lavage can be useful if FAST or CT scan is unavailable and considered positive if contains the following⁶:
- 5 mL of gross blood
- Enteric contents
- >100 000 RBCs per cc
- >500 WBCs per cc
- Elevated amylase level

INDICATIONS FOR LAPAROTOMY

Hemodynamic instability
Replacement of >40 mL/kg blood products⁸
Hollow viscus injury demonstrated by free intraperitoneal air or extravasated contrast on imaging
Clinical deterioration⁷

BOWEL INJURY

Jejunal perforation is the most common small bowel injury (Table 8.1).⁹
Crush injuries can result in damage to the transverse colon due to compression against the spine (Table 8.2).
Rapid deceleration can result in bowel injuries at fixed points such as the ligament of treitz, the ileocecal valve, and the rectosigmoid junction.
Delayed ischemic necrosis and perforation can result from mesenteric injuries.¹⁰

SPLENIC INJURY

The need for operative management in children with splenic injury is usually apparent within 24 hours of admission.¹²
Direct repair or partial splenectomy should be favored in children, but splenectomy may be required for ongoing insta-bility or multiple other injuries.¹³
Asplenic children are at increased risk for overwhelming postsplenectomy sepsis compared with adults and should receive vaccinations and antibiotic prophylaxis.¹⁴

TABLE 8.1 Small Bowel Injury Scale

Grade^a	Type of Injury	Description of Injury
I	Hematoma	Contusion or hematoma without devascularization
	Laceration	Partial thickness, no perforation
II	Laceration	Laceration <50% of circumference
III	Laceration	Laceration >50% of circumference without transection
IV	Laceration	Transection of the small bowel
V	Laceration	Transection of the small bowel with segmental tissue loss
	Vascular	Devascularized segment
Reprinted with permission from Moore EE, Cogbill TH, Malangoni MA, et al. Organ injury scaling II: pancreas duodenum small bowel, colon, and rectum. J Trauma. 1990;30(11):1427-1429.
^aAdvance one grade for multiple injuries up to grade III.

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Tags: Handbook of Pediatric Surgery

May 5, 2019 | Posted by drzezo in PEDIATRICS | Comments Off